Prevalence of Anxiety amongst Interns while Performing Treatments in Dental Colleges of Navi Mumbai: A Cross-sectional Study

1. Intern, Department of Conservative Dentistry and Endodontics, MGM Dental College and Hospital, Navi Mumbai, Maharashtra, India. 2. Intern, Department of Conservative Dentistry and Endodontics, MGM Dental College and Hospital, Navi Mumbai, Maharashtra, India. 3. Associate Professor, Department of Conservative Dentistry and Endodontics, MGM Dental College and Hospital, Navi Mumbai, Maharashtra, India.

Abstract

Introduction: Anxiety is one of the most commonly experienced disorders across gender and all ages. Dental anxiety seen in patients prior to or during treatment is a well-researched topic. However, anxiety experienced by interns while treating patients in the dental college is a lesser explored side of the same coin.

Aim: To evaluate and understand the prevalence of anxiety experienced by dental interns while performing treatments in a college clinical set-up and studies the various factors precipitating anxiety.

Materials and Methods: This cross-sectional study was conducted using google forms, amongst interns of five dental colleges in Navi Mumbai, Maharashtra, India, from July 2021 to October 2021. A sample size of 350 was derived by convenient sampling method. The parameters assessed via questionnaire through a Likert-type response scale included various factors precipitating anxiety amongst interns such as performing invasive dental treatments, lack of in-depth knowledge of procedures, age, attitude and medical conditions of patients, encountering complications while treating patients, presence of supervision and working with anxious peers. Chi-square test was performed to analyse collected data, extract results and draw a conclusion.

Results: The mean age of the participants was 23±2 years. A total of 350 participants, out of which 332 showed symptoms of anxiety while treating patients in clinics. No significant gender predilection was noted for anxiety (p=0.544). Factors precipitating anxiety included performing invasive dental treatments (p=0.0004), lack of in-depth knowledge of certain procedures (p=0.020), patient’s attitude (p=0.017), treating patients with certain medical conditions (p=0.035) as well as encountering complications while treating patients (p=0.022). A significant number of participants thought that anxiety leads to more procedural errors (p=0.010). The need to incorporate anxiety management in the dental curriculum was observed (p=0.023).

Conclusion: The results of the present study showed prevalence of anxiety amongst dental students and highlighted the need to incorporate anxiety management programmes in the curriculum. Preparing interns to cope with anxiety resulting from treating patients seems to be of importance for their future clinical practice.

Clinical anxiety, Psychology, Questionnaire, Stress

The definition of anxiety as adapted from the Encyclopedia of Psychology, ‘is an emotion characterised by feelings of tension, worried thoughts and physical changes like increased blood pressure’ (1). Dental anxiety among patients is a well-known and commonly researched aspect of dentistry (2),(3). The prevalence of dental anxiety has been found to vary in content, pattern, and level of fear across different cultures and different populations (4),(5),(6).

The stressful nature of dentistry starts early as dental students are expected to acquire a wide range of knowledge and a variety of skills to help them succeed in their studies and also in their future career. Dentists might experience occupational stress from their interaction with staff and patients, problems in the treatment of patients, time pressure and paper work (7),(8),(9). However, the anxiety dental interns face while working in the clinics, is an important but a lesser explored side of the two-way street. The dental clinical setting, which is a significant learning environment for undergraduate dental students, may induce anxiety, which in turn may adversely affect their clinical performance. Although, anxiety is subjective to individual experience, it may present in one of the following ways: symptoms like irrational fears, restlessness, irritability, nervousness, inability to focus and physical signs like increased heart rate, palpitations, sweating etc., (10). Anxiety amongst interns while performing dental procedures can have implications on their efficacy, efficiency, and productivity (11).

Dental students are known to be subjected to considerable levels of stress and anxiety during their training period, and this has been demonstrated in various studies (12),(13),(14),(15). Although there is conflicting data on the impact of stress on the academic performance of dental students (16), there is existing evidence in the literature indicating that high levels of perceived stress and anxiety result in psychological morbidity and emotional exhaustion. This may predispose them to professional burnout and decreased productivity (7). Although similar studies exist (17),(18), there is a need to assess the prevalence of anxiety amongst dental interns specifically in India as the curriculum, patient and environmental factors differ from other countries.

The lacunae in previously available studies and literature were that, very few studies have been conducted in India and none of them had been in the Navi Mumbai region which has five dental colleges (2),(19). The novelty of the present study was that it focused on the interns studying in the five dental colleges of Navi Mumbai region. These colleges have similar patient demographics and nature of students is also similar. Dental students, who are future frontline healthcare providers, need to learn about the techniques that can help them to overcome their own anxiety (20). A decrease in their anxiety levels would make them confident practitioners, who could in turn treat their patients well.

This cross-sectional study-based assessment of anxiety aimed to assess the prevalence of anxiety amongst interns in a college clinical set-up, the various factors precipitating that anxiety and gender predilection (if any). Another aim was to gauge the need for incorporating anxiety management in the dental curriculum. Null hypothesis for the present study was that there is no prevalence of anxiety amongst dental interns in a college clinical set-up, no factors precipitating anxiety and hence, no sex predilection with regards to anxiety experienced by interns.

Material and Methods

This cross-sectional study was conducted across five dental colleges of Navi Mumbai, India from July 2021 to October 2021. Ethical approval was acquired from the Institutional Ethics Committee of MGM Dental College, Navi Mumbai (Reg no. ECR/786/Inst/MH/2015/RR-18 & Abstract no. IN-001-02-22); participation in the present study was on a voluntary basis and an online informed consent was obtained from all participants.

Inclusion criteria: Only completely filled out forms by interns of five dental colleges were included in the study.

Exclusion criteria: Incompletely filled out forms and those previously diagnosed with anxiety by a physician were excluded from the study.

Sample size estimation: Based on a similar study (19), a power analysis and sample size estimation by convenient sampling method was performed. Power analysis showed that with a power of 1.28 and a significance level of 1.96, approximately 66 participants were required per study group. However, considering the dropout cases, 70 participants in each group were included. But the above study was not a comparative study and only considered dental students in various colleges in Navi Mumbai had been considered. Hence, required sample would be 70+70+70+70+70=350.

Study Procedure

Questionnaire was distributed to all interns (500) of five dental colleges of Navi Mumbai region via Google Forms. The respondents completed the questionnaires anonymously, and no data except gender and age were collected. A custom-made questionnaire was developed by the surveyors (Table/Fig 1). No previous questionnaire was referred to while designing the present study questionnaire. The questionnaire consisted of 18 multiple choice closed ended questions with choices based on a Likert-type scale The multiple-choice questions were aimed at assessing the various factors precipitating anxiety amongst dental interns and to understand the gender predilection (if any) associated with anxiety.

The options provided to participants were graded for the purpose of statistical analysis. Face validation of the questionnaire was done by 10 professors/validators within and outside the Institution. This was followed by a pilot study and statistical reliability testing was conducted and Crohnbach’s alpha value of 0.9 was derived.

Statistical Analysis

The statistical software used to calculate the sample size was Statistical Package for Scientific Studies (SPSS), software version 20.0 {(SPSS, Inc., Chicago, IL, United States of America (USA)} for windows. The collected data was converted to excel sheets and analysed. Chi-square test was performed to extract results.

Results

A total of 500 questionnaires distributed to interns via google forms across five dental colleges of Navi Mumbai, 398 responses were received, out of which a total of 350 completely filled forms were included and 48 forms were excluded from the study as 34 were incompletely filled and 14 had been previously diagnosed with anxiety. The response rate was 398 (79.6%) (398 out of 500). The mean age of the participants was 23±2 years. The distribution of participants according to age and gender has been presented in (Table/Fig 2).

No gender predilection was noted about symptoms of anxiety (p=0.544) as shown in (Table/Fig 3). There was presence of significant prevalence of symptoms of anxiety in 332 out of the 350 interns (p=0.053). No significant anxiety was found amongst interns while performing new or previously performed treatments. Performing invasive dental treatments such as extractions and sub-gingival scaling evoked significant anxiety (p=0.0004). Another factor noted in the present study which caused significant anxiety was the lack of indepth knowledge of certain treatments (p=0.020). The results also showed that anxiety levels reduced as students progressed from third year to internship. The influence of patient’s age in evoking anxiety amongst interns while treating patients was not significant. Other factors evoking anxiety included patient’s attitude (p=0.017) and medical conditions (p=0.035). The results also portrayed significant anxiety in interns when they encounter certain complications or challenges (p=0.022) during patient management.

No significant anxiety was noted when interns performed treatments under the supervision of faculty or if they were being evaluated by faculty members. Similarly, the study revealed no anxiety was present in interns treating patients while being observed by a peer, while working with a peer or while working with an anxious peer. A significant number of participants thought that anxiety leads to more procedural errors (p=0.010). Results showed that interns think that anxiety management should be a part of their academic curriculum was statistically significant (p=0.023) (Table/Fig 4).

Discussion

This cross-sectional study demonstrated the prevalence of symptoms of anxiety amongst interns in dental colleges of Navi Mumbai. Results portrayed that female interns are more likely to experience anxiety in a clinical set-up as compared to their male counterparts. The gender predilection of anxiety in the responses of this study however, was not statistically significant which may be attributed to the fact, that dental colleges of Navi Mumbai have more number of female interns than males. Out of total 255 females (95.3%) and of total 95 males (93.7%), said they had symptoms of anxiety. However, studies conducted by Holtzman JM et al.,; Farooq I and Ali S; showed that females were found to be more anxious than males probably because females are more responsive to a particular stimulus (like fear of the needle) than males [21,22]. Another study by Pierce KA and Kirkpatrick DR; showed similar results and stated that it could be because males tend to hide their fears due to their conventional gender role (23). The results of present study showed that there was no significant anxiety noted in interns while performing any new or previously performed procedures. This could be because interns only perform procedures that, they are well versed with and are always guided by their seniors or faculty members. Thus, they are not held solely responsible for the outcome of any procedure.

The current study depicted that anxiety was significantly evoked in interns while performing invasive treatment procedures like extractions and subgingival scaling which is similar to a study by Obarisiagbon A et al., (24). Another study by Kieser J and Herbison P also showed that students were most stressed by the prospect of surgical procedures (25). Lengthy procedures such as recording jaw relations and root canal treatments fail to evoke anxiety as these are taught to students in their pre-clinical curriculum.

The result of this study signified that anxiety levels reduced as students move from third to fourth year and then internship. It was in line with studies which show that pre-clinical students (first and second year) were found to be more anxious than clinical students (third and fourth year) (26),(27). This study also highlighted that anxiety is precipitated when there is lack of in-depth knowledge of procedures. It justified the reduction in anxiety levels as students progress from third year to internship as the knowledge and experience increases.

The study concluded that anxiety was not significantly influenced by the age of the patient. This may be because internship in Indian dental colleges is a one-year rotatory programme which exposes interns to various departments and thus they get to interact and treat a plethora of patients including paediatric and gaeriatric patients. Development of soft skills as one progresses from pre-clinical years to internship renders interns the ability to deal with patients of all ages without any anxiety.

A review by Jubhari EH and Rachellea K; suggests that it is often more difficult to manage exacting patients than polite and compliant ones (28). The above study too highlighted the influence of patient’s attitude and medical conditions on anxiety in interns. It could be attributed to the lack of knowledge amongst interns to deal with certain medical conditions or complications that arise when they treat patients in a clinical set-up.

When it comes to interns performing procedures under the supervision of faculty, the study results revealed that this factor does not contribute in significantly evoking anxiety amongst interns as they are not graded by the faculty nor do they undergo any examinations. As students progress from first year to internship, they develop a rapport with their faculty and feel a certain sense of comfort while performing treatments under staff supervision.

It was noted that interns do not significantly experience anxiety while working with or being observed by a peer. Working with an anxious peer also didn’t significantly affect anxiety levels. There exists a certain sense of familiarity and comfort between the individuals involved in treating the patients together or observing each other’s work which explains no anxiety. Secondly, lack of anxiety can be explained by the concept of “Peer assisted learning” which has been encouraged by dental colleges in recent times. Peer assisted learning involves interns to interact with their colleagues or seniors, assist them in their cases and practice in a protected learning environment (29),(30).

It was also noted in this study that most interns believe that anxiety significantly affects their work and they tend to make more procedural errors. As the authors know from the definition of anxiety as stated in the Encyclopedia of Psychology (1), that it affects a person mentally as well as physically, thus it is only justified that overall efficacy of an intern might reduce when he/she experiences anxiety while treating patients.

An important aspect of this study was also to understand the need of incorporating anxiety management programs in the curriculum for interns and the results showed an overwhelming response in its favor. A study by Basudan S et al., also concluded similar findings which highlighted the importance of providing support programs and implementing preventive measures to help students with anxiety and stress (31). Anxiety level during clinical classes is relatively high in students and preparing them to cope with stress resulting from treating the patients seems to be of importance (32). (Table/Fig 5) is showing comparison of present study with similar studies (24),(25),(26),(27),(28),(31).

Limitation(s)

The sample was not representative of the population of all interns across India since they were from one particular region. Therefore, such studies need to be carried out, using the same methodology, in most dental colleges in the country. Moreover, this was a crosssectional study, so it seems necessary to continue the research as a longitudinal study for the same interns in the following years. It could be interesting to perform such follow-ups to observe the changes in the prevalence and levels of anxiety in individuals. Additionally, the data was based on a questionnaire, which might be influenced by acquiescence bias wherein, study respondents tend to agree with study questions, without their response being a true reflection of their own position or beliefs because, it is easier to say yes or answer in a way which pleases a researcher or to just complete the study.

Conclusion

The results of the present study showed the 94.8% of dental interns showed symptoms of anxiety. Various factors influencing anxiety include performing invasive dental treatments, patient’s attitude, medical conditions of the patient, encountering complications during patient management and lack of knowledge of certain procedures. The present study showed that no statistically significant gender predilection with respect to anxiety symptoms. However, research on this aspect needs to be continued to better understand this aspect of anxiety affecting interns. This study concluded that there is a significant need of incorporating anxiety management programmes in the curriculum. An anxious intern will tend to make procedural errors which may be otherwise avoidable. Thus, anxiety management programs must be implemented before the start of practical clinical classes. The acquired knowledge will then prove useful in their future professional career.

DOI and Others

DOI: 10.7860/JCDR/2023/60120.17964

Date of Submission: Sep 07, 2022
Date of Peer Review: Oct 15, 2022
Date of Acceptance: Jan 04, 2023
Date of Publishing: Apr 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
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ETYMOLOGY: Author Origin